POC-EN-W - International Circumcision Information Reference Centre

Post Operative Care
for Infant or Childhood
Circumcision
An Introductory Guide
First Edition
Inter-Circ International Circumcision Forum
Copyright Notice
This publication is the copyright of
The International Circumcision Forum © Inter-Circ 2013-14
All rights reserved.
Any redistribution or reproduction of part or all of the contents in any form is
prohibited other than for the following purposes:
• Printing or downloading this document to a local hard disk for your personal and
non-commercial use,
• Copying the entire document, electronically or in printed form, to individual
third parties for their personal use. No charge shall be made and the Inter-Circ
International Circumcision Forum shall be identified as the source of the material,
• Providing a standard hyperlink from your personal web site or blog to this
document subject to it opening in a new browser window or tab, complete with
the Inter-Circ identity in the URL line of the browser,
• Quoting parts of this publication for scholarly, academic or review purposes
provided the source is acknowledged as above.
You may not distribute or exploit the content of this document for commercial
purposes, nor may you transmit it or store it in any other website or other form of
electronic retrieval system without our explicit written permission.
POC-EN 1407-1
Written requests for this type of use should be directed to:
[email protected]
Post-Operative Care for Infant or Childhood Circumcision
Post Operative Care for Infant or Childhood Circumcision
An Introductory Guide
Authors
Inter-Circ Moderation Team
Medical Reviewer
John Murray M.D.
First Edition
Last updated July 2014
The Inter-Circ International Circumcision Forum
is a volunteer-run pro-circumcision group. The purpose of the group is to make
known the benefits of circumcision, to debate topical issues related to the subject
and to offer advice both pre- and post-circumcision.
The Inter-Circ forum is located at:
http://groups.yahoo.com/group/inter-circ/
Disclaimer
Whilst every effort has been made to ensure the accuracy and applicability of the
information contained within this publication, it is intended as an introductory
guide only and not as a source of complete or totally indisputable information. The
authors stress that if you are in doubt about the post-operative care for your son, or
you are concerned with some aspect of his recovery, then you should immediately
seek the advice of your medical practitioner or surgeon. This guide is not intended
as a substitute and nothing herein is to be construed as ‘medical advice’.
If your doctor has given you specific instructions regarding after-care you should
follow those whenever they conflict with the advice in this booklet.
1
Post-Operative Care for Infant or Childhood Circumcision
Contents
Page
3 Introduction
3 Before leaving your circumcision provider
3 It looks horrible! What have I done?
4 Circumcision methods
4 General care
4 Food
4 Swelling
4 Peeling glans
5 Underwear and trousers
5 Nappy/Diaper
5 Bathing
5 Healing
6 Urination
6 Pain relief
6 Infection
6 Sports, etc
7 Time off school
7 Possible problems
7 Plastibell, or equivalent, method
7 General
8 Bleeding
8 Gomco, Mogen or Forceps Guided method
8 Bleeding
8 Stitches
8 Dressings
8 Adhesion
9 Explaining circumcision
9 My question is not answered?
10 Recommended links
11 Your notes
12 Penile anatomy
2
Post-Operative Care for Infant or Childhood Circumcision
Introduction
The circumcision of your son can be an emotionally traumatic time for you as
parents. Any surgical procedure carries with it anxieties, concerns and potential risks.
This publication aims to allay your anxieties, address your concerns and explain in
simple terms what to do, and what to look out for, after your son’s circumcision. We
hope you will find it useful in aiding his recovery.
Please note that this publication refers to circumcision of infants and pre-puberty
boys only; not teenagers or adults for whom there is a companion booklet.
Before leaving your circumcision provider
Before you have left your circumcision provider, the doctor, surgeon or nurse
should be satisfied that your son is not bleeding and that he can urinate without
obstruction. Fortunately these complications are rare. Small bleeds are to be
expected as with any surgical procedure, but heavy bleeding may be indicative
of the parting of the wound or incomplete sealing of the deeper blood vessels. In
either case blood loss would be significant, especially for an infant, and immediate
medical attention would be required.
Experiencing difficulty or pain when urinating could also be serious and should
receive urgent medical attention. Note however that the first urination might ‘sting’
a bit – this is nothing to worry about and will go away after that first time.
Ensure that you know for how long to wait before changing the first bandage (if
one has been used).
Ask the doctor for his emergency contact number in case there are any problems.
It looks horrible! What have I done?
Immediately after circumcision your son’s penis may look very unpleasant. It will
look bruised, bloody and swollen and it will feel sore, painful and uncomfortable.
This can be a difficult time even for parents who were happy and confident with
their decision to have their son circumcised but who then feel overwhelmed by the
sight and sensitivity of his penis at this early stage.
Anxiousness and regret are common feelings to experience in the immediate
post-circumcision period and this is completely natural. It is important to remember
three things after circumcision: firstly, that the penis will take time to heal; secondly,
that every day that passes yields an improvement; and thirdly, that usually there is
nothing to worry about as significant complications are rare.
3
Post-Operative Care for Infant or Childhood Circumcision
Circumcision methods
There are two major methods of performing circumcision for an infant or
pre-puberty boy.
The occlusion method uses a plastic bell or equivalent clamp which remains on the
boy’s penis for a week or so and works by depriving the foreskin of its blood supply,
whereapon it dies, turns black and falls away with the plastic ring in 7 to 10 days.
Typical devices are the Plastibell, Smart KLamp or Ali’s Clamp.
In the excision method the foreskin is pulled forward, temporarily clamped in
front of the glans, and then cut off with a scalpel. The cut edges are then stitched
together. Stitches may, however, be unnecessary for an infant. Typical names for this
method are Gomco Clamp, Mogen Clamp or Forceps Guided.
The two methods require slightly different after-care. You should ask your doctor
which method was used and follow the appropriate after-care section.
General care
Food
A baby should be suckled or given his bottle immediately after the operation. He
should be cuddled and reassured as much as possible.
Older children should be given a sweet drink (eg Coke) and some chocolate
whilst waiting for their penis to be checked. This will reduce any tendency to
post-operative shock.
Swelling
After the operation your son’s whole penis may be swollen and look very bruised.
This is a normal effect of both the injected anaesthetic and the surgery it necessarily
receives. The swelling and bruising will gradually reduce over the next week or two.
The more of the inner foreskin that is left the more swelling there is likely to be. As
long as the swelling doesn’t cause any pain, nor obstruction, when urinating, there
is usually nothing to worry about.
For older boys, raising the penis skyward (as indicated in the following section) will
allow the lymph fluid, which causes the swelling, to drain away.
Swelling will also reduce significantly once the stitches are all out.
Peeling glans
Sometimes, when an older boy is circumcised, the glans may peel (similarly to
sunburn) as it adjusts to being permanently exposed. This is nothing to worry about
but some moisturising cream can usefully be applied at this time.
4
Post-Operative Care for Infant or Childhood Circumcision
Underwear and trousers
If your son normally wears boxers he may find that they give insufficient
post-operative support. You may wish to consider buying him some briefs which
will hold his penis in position and thus reduce the unaccustomed frictional
stimulation of the glans; which it would otherwise receive if allowed to move freely.
Keeping the penis pointing upwards in the tighter underwear helps drain away
lymph and thus reduce the swelling. Padding his underwear in the frontal area will
protect against knocks and hold his penis in place.
He should avoid tight trousers or jeans so as not to produce pressure and rubbing
on the penis from them and to allow more air to circulate for promotion of healing.
Nappy/Diaper
A baby’s nappy/diaper should be changed as soon as possible each time it
becomes damp or soiled.
Bathing
Until any initial dressing is off no baths or showers should be taken.
Subsequently, a baby should be given a daily bath as usual whilst a boy can shower
or bath normally (until healing is complete, a shower is preferable to a bath for an
older boy so that he does not have the wound in dirty water). When using a bath,
add some table salt or Epsom Salts to the bath water to promote healing.
If the doctor has given you some antiseptic powder then use it as directed.
Healing
Babies and young children tend to heal quite quickly, but factors such as age,
general health, the method used and the style of circumcision performed can all
affect how long healing takes. It is also possible that those with prior or existing
penile problems such as BXO or phimosis, or conditions such as diabetes, may
require a longer period of healing.
As a guide, a baby will normally heal fully in less than two weeks whilst a boy
approaching puberty may take up to 6 weeks. The frenulum, if it has been removed,
is usually the last place to heal. It commonly heals completely within a week of the
main wound.
Do not apply any antiseptic cream to your son’s penis, nor add any antiseptic to
bath water, unless prescribed by your doctor. Whilst they do help to kill germs, most
are corrosive to new skin and actually slow down healing. In the rare cases where an
infection develops, see a doctor as soon as possible.
5
Post-Operative Care for Infant or Childhood Circumcision
It can be beneficial and very soothing for an older boy to soak the wound for 10
to 15 minutes a couple of times a day in a cupful of cooled, boiled water to which
has been added a teaspoon of table salt or Epsom Salts. This promotes healing and
reduces the risk of infection.
Urination
For older boys, do not be surprised if his urine tends to spray instead of forming
a neat stream for the first few days. This is a natural result of the swelling and will
correct itself as the swelling subsides. He may find it more convenient to sit rather
than stand for urination during this time.
Pain relief
A local anaesthetic will normally continue to be effective for a couple of hours
after the operation. Your son should not be in pain after this but may experience
significant discomfort for a few days. If this happens then he should be given
appropriate pain relief for his age. Be sure to read the instructions regarding dose
and frequency carefully.
Do NOT use Asprin based pain relief as this thins the blood and makes bleeding
more likely. Paracetamol or Ibuprofen based medicines are to be preferred.
If a baby does not settle then you can use an infant pain relief (eg Infant Calpol) or
consult the doctor.
Infection
With care, infection rates in the post-operative period are very low, and where an
infection is present it is normally mild and easily treatable with a standard course of
antibiotics. One common error is mistaking lymph fluid for pus. Lymph fluid is the
watery yellow-looking fluid which collects in the penis and causes swelling. Leaking
a little lymph fluid is normal and is not a sign of infection. Pus, on the other hand, is
a thicker, yellow or white, almost custard-like secretion which will smell. If in doubt,
consult your doctor.
Reducing the risk of infection can be achieved by practising good hygiene
techniques, changing any dressings regularly, washing and drying the penis
appropriately, and using an anti-bacterial product appropriate for wounds, such
as anti-bacterial Vaseline or Betadine dry powder spray. Do not use strong liquid
antiseptics as these can destroy newly forming skin and slow down healing.
Sports, etc
Your son should not compete in fast moving or contact sports such as football,
soccer and rugby, nor in running and cycling, for a week after circumcision.
6
Post-Operative Care for Infant or Childhood Circumcision
He should also avoid swimming as the chlorine in the water may sting the wound
and delay healing. Sea swimming is definitely contra-indicated to avoid infection.
Time off school
There is no absolute need for a boy to take time off school after circumcision, but he
may find it very hard to concentrate on work for the first day or two and so it may
be useful for him to take a few days off depending on how he feels. Many parents
arrange to have their sons circumcised during school holidays where possible.
Possible problems
Notify the doctor immediately if:
• There is persistent bleeding
• There is excessive swelling
• The boy is in significant pain or the baby fails to settle
• The wound becomes infected
• The stitches (if used) have not fallen out after 14 days
• The plastic ring or equivalent (if used) slips down onto the shaft of the penis
• The plastic ring or equivalent (if used) has not fallen off after 8 days
Plastibell, or equivalent, method
General
Very little special care is needed when this method is used.
The nature of the plastic bell should ensure that the circumcision cannot come
into contact with the glans, which may be a little raw from separation of adhesions.
A little petroleum jelly (Vaseline) smeared on the wound and glans each time
the baby is changed will help prevent the two fusing together and forming ‘skin
bridges’:
For older boys the cut edges should always be pushed back and petroleum jelly
applied morning and evening as well as after bathing.
A dark brown or black area around the plastic ring is perfectly natural. This is dead
skin and will fall away along with the ring. The skin under the string may also
become soft and yellow (like a baby’s umbilical cord stump).
The bell will fall off naturally after about a week, leaving a fully healed circumcision.
Do not attempt to pull the ring off your baby even if it seems loose. It sometimes
hangs by the last vestige of dead skin, but leave it be.
An older boy must be warned against attempting to speed up the release of the
bell by pulling at it, even when almost off. It may be necessary to prevent a baby
7
Post-Operative Care for Infant or Childhood Circumcision
or young child having access to his penis during healing by the use of suitable
clothing.
Bleeding
There may be a little pink or red staining of the nappy or underwear for a few
hours after the circumcision and again when the bell separates. There should not
be any significant or sustained bleeding – should this occur contact the doctor
immediately or take the child to the Hospital Emergency Department. This is
especially important for infants who have only a small total blood volume.
Gomco, Mogen or Forceps Guided method
Bleeding
There may be a little staining of the bandage for a few hours after the circumcision.
There should not be any significant or sustained bleeding.
If there should be excessive bleeding:- using the thumb and index finger, make a
ring around the top of the penis and squeeze tightly for FIVE MINUTES.
lf the bleeding does not stop contact the doctor immediately for advice or
take the boy to the Hospital Emergency Department.
Stitches
If stitches have been used, these will fall out by themselves within 7-10 days and no
special action normally needs to be taken about them. In the case of older boys you
can also ask the doctor or nurse to remove the stitches after this time to ensure that
‘stitch tunnels’ cannot form.
Dressings
Your son may have only a light dressing over the wound itself or the doctor may
have applied a bandage to the whole penis. In either case, if the dressing falls off
early do not worry. There is no absolute need for another dressing to be applied, but
you can use a light one if you wish.
If the first dressing has not already fallen off within 24 hours (or such other period
as directed by the doctor), it must be removed by soaking in a warm bath. Take
plenty of time; gently release the dressing, stopping whenever you start to
feel any resistance to its removal – let the water soak off the clotted blood and
then continue. Some boys, even quite young ones, may be happier doing this
themselves under supervision.
Adhesion
The glans may be a little raw from separation of adhesions. The edge of the foreskin
should be pushed back off the glans and a little petroleum jelly (Vaseline) smeared
8
Post-Operative Care for Infant or Childhood Circumcision
on the wound and glans each time the baby is bathed or changed to prevent the
two fusing together and forming ‘skin bridges’.
For older boys the cut edges should always be pushed back and petroleum jelly
applied morning and evening as well as after bathing.
Explaining circumcision
If your son was circumcised as a baby or toddler he will have little or no memory of
the event. It is important to take an early opportunity, commensurate with his age
and understanding, to point out why his penis may look different from some other
boys – before they do. This is usually soon after starting school when boys compare
penises at the urinals.
Whenever you have this dialogue, it is important that you be positive to help him
feel good about his changed body image and counter any teasing he may have
from friends. Encourage him to joke and laugh with them, and not to be upset by it.
It greatly helps if his father or other members of the family have been circumcised
because boys look up to their dads as role models.
Otherwise, if your son has been circumcised for medical reasons after infancy, point
out that there are many health and hygiene benefits to being circumcised. Explain
that for Jewish and Muslim boys, and in many places, like Africa and the Philippines,
it is admired as a mark of coming-of-age and manhood.
If you judge your son is mature enough you might choose to include the
sexual dimension and the health benefits and preference of female partners for
circumcised penises.
Failure to properly explain circumcision and its benefits to your son will lead to him
obtaining erroneous information from his peers or, worse still, reading and believing
the utter nonsense promulgated on the internet by the anti-circumcision fanatics.
The Gilgal Society has a leaflet (All About Being Circumcised) which may be useful
in explaining things to a 7-10 year old.
A leaflet on the health benefits of circumcision can be obtained from the Circ-Info
web site.
My question is not answered?
Although every effort has been made to ensure that this publication is as
comprehensive as possible on all of the major post-operative issues after your son’s
9
Post-Operative Care for Infant or Childhood Circumcision
circumcision, it is inevitable that it will fail to answer every question or concern that
may be experienced during the post-operative period.
We always recommend asking your medical practitioner or surgeon for advice if
you are in any doubt or if you are concerned about any aspect of recovery. If you
have not found a suitable answer to your question within this publication then you
should contact your doctor for information.
It is essential that you call or visit your doctor immediately if you have serious
concerns about your son’s recovery, e.g. bleeding, infection or the wound opening.
For further help and support, you can always ask questions at the Inter-Circ
International Circumcision Forum. The membership can help advise you on
the basis of their own knowledge and experience. The forum is not, however, a
substitute for medical advice from your own medical practitioner.
We would welcome suggestions for any improvement to this guide. Please submit
them via the Forum.
Recommended links
The Inter-Circ International Circumcision Forum
http://groups.yahoo.com/group/inter-circ/
The Circlist Web Site
http://www.circlist.com/
The Circumcision Helpdesk Web Site
http://www.circumcisionhelpdesk.org/
The Circ-Info Web Site
http://www.circinfo.net/
10
Post-Operative Care for Infant or Childhood Circumcision
Your notes
Use this space to record hospital instructions or other information that you may
have acquired. You may also find it helpful to keep a diary of the event and the
process of recovery.
11
Post-Operative Care for Infant or Childhood Circumcision
Penile anatomy
Uncircumcised penis
with foreskin in normal position
Foreskin
Uncircumcised penis
with foreskin retracted
Urethral opening
(Meatus)
Shaft
Preputial
opening
Glans
Circumcised penis - tight
Coronal
rim
Circumcised penis - loose
Remnant
of foreskin
Coronal
sulcus
The appearance of the circumcision may vary according to the method used and the
intentions of the operator. The aim should be to achieve full glans exposure but initially
the remains of the foreskin may encroach upon it. If the circumcision is done in infancy
or early in childhood, the foreskin stump will usually fail to grow as the penis develops
and full glans exposure will often be apparent before or by puberty.
12
Post-Operative Care for Infant or Childhood Circumcision
Ventral (underside) view
to show the Frenulum
Frenulum
retained
Frenulum
excised
The frenulum is an ‘elastic band’ type of
structure which sits in the groove on the
underside of the glans. It tethers the foreskin
to it as a means of stabilising the foreskin
and assisting the re-covering of the glans as
an erection subsides. If the frenulum is tight
(a common condition known as frenulum
breve) it can cause problems, particularly
inhibiting sexual activities.
For this reason and because the removal
of the foreskin renders it redundant,
the frenulum is usually (but not always)
removed as part of the circumcision.
This device is inserted over the glans and
under the foreskin. To facilitate this, the
adhesions between the two are separated
Plastibell
with a blunt probe and the dorsal (top) of
Circumcision
the foreskin is cut with scissors along it’s
length, enough for the bell to reach the
coronal sulcus.
A mark having been made to determine
the amount of foreskin to be removed,
surgical thread is tied very tightly around
it on the outside of the foreskin, drawing it
into a groove in the skirt of the bell. When
done, the handle of the bell is broken off to
leave the ring of plastic. Most of the foreskin
is then trimmed off with scissors leaving a small margin above the thread. This turns
blue/black as it necrotises (dies) in about a week or ten days, leaving a sealed and healed
wound needing no further attention. The Plastibell comes in a range of sizes with a
punched card to measure the penis and choose the correct one. It works fine for babies
and toddlers but is often unsuitable for older boys where the foreskin is more developed
and too tough for the thread to make a good excision.
13
This publication is the copyright of
The International Circumcision Forum © Inter-Circ 2013-14.
All rights reserved.